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Friday, July 1, 2011

A virtual avalanche of articles has appeared in the medical literature recently discussing opioid analgesics for chronic pain. Almost without exception, the news and views are disparaging; in some cases reflecting a poor quality of evidence and, in others, conveying biases of the authors. Ongoing concerns about opioid misuse, abuse, and fatalities may be obscuring a problem of equal or greater importance — intentional self-harm, suicide, by drug overdose among persons with chronic pain. It may be time for a rational reassessment of this problem before it is too late.

Most recently, the government released comparable data on drug-related suicide attempts by men during 2005 to 2009 [SAMHSA 2011]. In 2009, there were a total of 77,971 emergency department (ED) visits for drug-related suicide attempts among males of all ages; 27,700 involving pain-reliever medications. ED visits for suicide attempts among males aged 35 to 49 involving “narcotic pain relievers” (ie, opioids) almost doubled from 2005 to 2009, while the numbers almost tripled among men aged 50 and older.

Of some importance, there were more than 27,000 cases of attempted suicide by men using drugs that treat anxiety or insomnia. And, while overall numbers of suicide attempts are less in men than in women, suicide ranks as the 7th leading cause of death in males, nearly 4 times the rate of females.

As usual, the government made no attempt to assess how many of the persons attempting suicide were suffering unresolved chronic pain. The biased assumption is that the incidents were a result of substance abuse, as SAMHSA Administrator Pamela S. Hyde states: “While we have learned much about how to prevent suicide, it continues to be a leading cause of death among people who abuse alcohol and drugs. The misuse of prescription drugs is clearly helping to fuel the problem.”

Other reports have more clearly depicted a connection between chronic pain and suicide. Writing in a special supplement to the journal Pain Medicine, Martin D. Cheatle, PhD, observes that comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain [Cheatle 2011]. The true numbers of failed attempts and successful suicides are unknown and may never be determined, he says; yet, “risk factors for suicidal ideation are so high in the chronic pain population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain.”

Cheatle notes that many persons with pain experience hopelessness and isolation, and they endure many losses, including work and family roles. Some fear that their pain symptoms will be minimized or considered as evidence of any underlying mental disorder. One survey found that half of patients with chronic pain had serious thoughts of committing suicide, another found that roughly 1 in 5 had current passive suicide ideation, 13% had active thoughts, 5% had a plan for suicide, and 5% reported a prior suicide attempt. Drug overdose was the most commonly reported plan for committing suicide.

The recently released Institute of Medicine (IOM) report on “Pain in America” also paid special attention to the effects of chronic pain on suicide risks [IOM 2011, also see UPDATEhere], as had earlier reports [Tang and Crane 2006]. Relative to controls, risk of death by suicide is at least doubled in patients with chronic pain. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Suicidality is particularly problematic in persons with chronic severe headaches, and people with more than one type of chronic pain are almost 3 times more likely to attempt suicide. One study found that military veterans with severe pain were one-third more likely to die by suicide than those without pain or with only mild-to-moderate pain.

Eight risk factors for suicidality in chronic pain have been proposed [Tang and Crane 2006]. Four are pain-related: the type, intensity, and duration of pain, and sleep-onset insomnia co-occurring with pain. Four factors are psychological: helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and coping or problem-solving deficits.

The ugly truth may be that suicide is often an unintended consequence of undertreated or mistreated chronic pain in America, and opioids are only one of several involved drug classes. Cheatle recommends that healthcare providers should be alert to the presence of depression and the risk of suicide in patients with long-term, chronic pain. Routine screening for depression or other mental disturbance is advised. Mental status of the patient should be taken into account when prescribing large amounts of potentially lethal medications; opioids, certainly, but also non-opioid analgesics, benzodiazepines, and other psychotropic drugs. For patients determined to be at high and/or immediate risk of self-injury, referral to emergency psychiatric services is recommended.

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